ATI RN
high risk labor and delivery nclex questions Questions
Question 1 of 5
The clinical nurse educator is providing instruction to a group of new nurses during labor orientation. Which information regarding the factors that have a role in the initiation of labor should the educator include in this teaching session? (Select all that apply.)
Correct Answer: B
Rationale: Step 1: Natural oxytocin is a hormone that plays a crucial role in initiating labor by stimulating uterine contractions. Step 2: Other substances like prostaglandins also contribute to the initiation of labor by promoting cervical ripening and uterine contractions. Step 3: Therefore, the correct answer is B as it accurately reflects the role of natural oxytocin and other substances in the initiation of labor. Summary: A: Progesterone levels becoming higher than estrogen levels is not directly related to the initiation of labor. C: While stretching, pressure, and irritation of the uterus and cervix can contribute to labor, they are not the primary factors in labor initiation. D: The secretion of prostaglandins from the fetal membranes actually increases during labor to facilitate the process, so this statement is incorrect.
Question 2 of 5
An infant was born 1 minute ago and the Apgar score is being assigned. The infant has blue extremities, minimal flexion, a weak cry, a heart rate of 110 beats per minute, and coughs and pulls away when suctioned. How many points should be assigned? Record your answer using a whole number:
Correct Answer: A
Rationale: The correct answer is A: 3 points. Apgar scoring assesses the newborn's overall condition at 1 and 5 minutes after birth. In this case, the infant's Apgar score should be 3 because the baby displays signs of mild distress with blue extremities, weak cry, and minimal flexion. The heart rate of 110 BPM and response to suctioning indicate some normal function. Each category (color, heart rate, reflex irritability, muscle tone, and respiratory effort) can score up to 2 points, totaling 10 points. Blue extremities and weak cry correspond to 1 point each, while minimal flexion corresponds to 0 points. The heart rate (110 BPM) and response to suctioning indicate 2 points each, totaling 3 points. Therefore, the correct score is 3 points. Choices B, C, and D are incorrect as they do not accurately reflect the severity of the infant's condition based on the Apgar
Question 3 of 5
A primigravida has just been examined. The examination revealed engagement of the fetal head. The nurse is aware that this means which of the following?
Correct Answer: A
Rationale: The correct answer is A because engagement of the fetal head means the widest part of the head (biparietal diameter) is at the level of the ischial spines, indicating the head has descended into the pelvis. Choice B is incorrect as -2 station refers to the presenting part being 2 cm above the ischial spines, not at the level. Choice C is incorrect because engagement does not necessarily mean the head is well flexed. Choice D is incorrect as the ability of the head to pass under the pubic arch is not determined solely by engagement.
Question 4 of 5
A 40-year-old G2, P1 woman is admitted to the labor and delivery unit with contractions 6 minutes apart. She is 36 weeks pregnant, has a history of placenta previa, and is currently experiencing moderate vaginal bleeding. What should the nurse be prepared to do?
Correct Answer: C
Rationale: The correct answer is C: Initiate external fetal monitoring. In this scenario, the patient is at 36 weeks of gestation with a history of placenta previa and moderate vaginal bleeding, indicating a high-risk situation. External fetal monitoring allows for continuous assessment of the fetal heart rate and uterine contractions, which is crucial for identifying signs of fetal distress or complications related to placenta previa. This monitoring can help guide timely interventions and decision-making to ensure the safety of the mother and baby. Performing a vaginal examination (A) may increase the risk of bleeding in cases of placenta previa. Artificial rupture of membranes (B) can also lead to increased bleeding and should be avoided in this situation. Encouraging ambulation (D) is not recommended due to the risk of exacerbating bleeding and potential complications.
Question 5 of 5
A sterile vaginal examination completed on a patient revealed the presenting part to be the mentum. What is this presentation known as?
Correct Answer: A
Rationale: The correct answer is A: Face presentation. In this presentation, the mentum (chin) is the presenting part. The chin is the prominent part of the face, making it a face presentation. In a face presentation, the fetus is in a position where the head is extended rather than flexed. This can lead to complications during delivery. Summary: B: Breech presentation - In breech presentation, the baby's buttocks or feet are the presenting part. C: Vertex presentation - In vertex presentation, the baby's head is the presenting part with the chin tucked towards the chest. D: Shoulder presentation - In shoulder presentation, the baby is positioned transversely in the uterus with one or both shoulders presenting first.